Safety recommendation
It is recommended that NHS England and NHS Improvement revises the Never Events list to remove events, such as those presented in this national learning report, that do not have strong and systemic safety barriers.
Response:
We agree that the systemic barriers for some Never Events are not as strong as others and following on from CQC’s thematic review ‘Opening the Door to Change’ commenced a programme of work to review the list of Never Events to identify which barriers are not as strong as was initially thought.
We are grateful to HSIB for their contributions so far to this work. Review of the Never Events Framework and Never Events List will be an ongoing process, as it has been since its first iteration in 2009.
Response received on 16 April 2021.